HospitalInspections.org

Based on interview and record review, the hospital was not in compliance with §42 CFR 489.24, Special Responsibilities of Medicare Hospitals in Emergency cases, in that,

1 of 1 patient (Patient #1) was not transfered to an inpatient psychiatric treatment facility after the 10/29/2021 medical screening examination determined Patient #1 required inpatient psychiatric treatment.

Cross refer to Tag 2409

Based on record review and interview, the facility failed to transfer 1 of 1 patient (Patient #1) to an inpatient psychiatric treatment facility after the 10/29/2021 medical screening examination determined Patient #1 required inpatient psychiatric treatment.

Findings

Patient #1's Medical Screening Examination reflected, "16:50 patient continued to exhibit agitated behavior. He demanded his medications that included Neurontin and Keppra. These were administered ...has repeatedly proclaimed that he is suicidal and will try to kill himself. I asked Behavioral Health Services to evaluate the patient at bedside and they are recommending inpatient psychiatric treatment. The patient is voluntary agreeing to that. However I have been told that there are no psychiatric beds available. I have asked the hospitalist to evaluate the patient here and admit until a psychiatric bed is available."

Patient #1's Discharge Summary reflected, "15:30 PM ...Suicidal Ideation ...Alcohol Intoxication ...Agitation ...No resolved hospital problems ...Hospital Course: Patient admitted as no (Psychiatric) beds available ...fully oriented. Patient is agitated and actively suicidal...currently in Police Custody and they wanted to take the patient to (named hospital). It is indicated to Police Chief that we (Hospital) wanted to transfer the patient to (named hospital) when we have bed availability, but Chief said that he wanted the patient discharged to Police as he is in Police Custody and they wanted to take him to (named Hospital). Patient does not need any treatment in hospital currently and medically stable and discharged to Police Custody ..."

Patient #1 did not have a transfer ordered by the physician.

Patient #1 did not have a transfer secured with an accepting hospital or physician.

Patient #1 did not have a Memorandum of Transfer information including documentation of education of risk and benefits, nurse to nurse or physician to physician report.

Patient #1 was transported by the police from hospital to hospital.

During the inpatient record review and interview on 6/29/2022 ending at 11:55 AM, Personnel #9 navigated the record and stated the patient was discharged at 16:30 to the police and there was no documented transfer from hospital to hospital.

During a telephone interview on 7/06/2022 at 2:06 PM, Personnel #11/Physician was asked what emergency condition the patient had. Personnel #11 stated suicidal ideation. He was intoxicated. He had risk of Alcohol withdrawal. We were looking at signs and symptoms and scoring 0-5. The patient had no withdrawal symptoms but was agitated and trying to hurt himself.

Personnel #11 was asked if the patient was medically cleared when he was admitted. Personnel #11 stated we tried to transfer - so yes; he was cleared but we admitted because there was no (Psychiatric) bed to send him to.

Personnel #11 was asked if the facility has psych services with psych beds. Personnel #11 stated no. We have medical beds.

Personnel #11 was asked if the patient was threatening. Personnel #11 stated he was violent, actively suicidal, and under the influence of alcohol. Medically we were not doing anything for him. We gave him Ativan to calm him. He was in custody of the police without insurance so (named hospital) was his only option. I was initially concerned we are not equipped for a violent patient, but they (staff/facility) said we can take care of it. Police Chief (Chief/Captain) was insisting they would take him to (named hospital). We told him (Chief/Captain) we had to take him (Patient). Chief asked if medically stable. We said yes. Chief insisted we discharge the patient.

Personnel #11 was asked what kind of treatment the patient receive for his psychiatric state. Personnel #11 stated we gave him 3 to 4 doses of Ativan, and Keppra.

Personnel #11 was asked if he spoke with Chief/Captain (police) about the patient being medically stable for transport and transporting to (named hospital). Personnel #11 stated yes, I did talk to him. He was asking if we (police) can take the patient. We told him (police) a bed was not available when requested. He said we want you to discharge him so they can take him. They know it was a waiting game. I wander if it was because they (police) had personnel here and they were tired of waiting and wanted to take him over there. Our goal was to bridge his care to wait for an available bed.

Personnel #11 was asked if he told the Chief/Captain that the transfer needed to be a hospital-to-hospital transfer. Personnel #11 stated no I did not have that conversation. He (Chief/Captain) spoke to someone in patient relations. I don't remember who.

Personnel #11 was asked if he (physician) spoke with the patient relations person about discharging to the police. Personnel #11 stated yes, they talked to me as well. They said it should be fine.

Personnel #11 was asked if the patient was threatening the staff or was an uncontrolled patient. Personnel #11 stated we gave him a urinal. He (patient) trashed it, hitting it on his head. He hit his head on the bed railing in ER (emergency room/Department). He (patient) was hand cuffed. He tried to hit his head on wall. We thought he (patient) may throw things at the staff, but I don't recall that happening.

Personnel #11 was asked if the patient remained suicidal at discharge. Personnel #11 stated yes.

Personnel #11 was asked if he contacted (named hospital) after the police took the patient knowing they were going to that hospital. Personnel #11 stated no doc-to-doc report was done. That occurs after the transfer is secured. Personnel #11 was asked if he discussed risk and benefits of transfer with the patient. Personnel #11 stated no, the patient was voluntary and in the custody of the police. I did not personally discuss that with him. That would already have happened in the ER.

The facility's EMTALA Policy required securing a hospital to hospital transfer. The policy allowed,
"Transportation
In the event a Patient requires Transfer, the Patient will be transported depending on the needs of the Patient as identified by the Transferring physician. Appropriate equipment and staff, as ordered by the Transferring physician, will accompany the Patient in the transportation vehicle.

Private Transportation Exception
If the Patient (or legally responsible person) declines transportation by ambulance and it is determined by the physician that private transportation is clinically appropriate, the Transfer by private transportation should be treated in accordance with this policy and documented appropriately.

If the Patient (or legally responsible person), after being advised of the risks and benefits, refuses transportation by ambulance and it is determined by the physician that private transportation may not be clinically appropriate, the Transfer should be treated in accordance with this policy and the refusal of the ambulance transportation should be appropriately and specifically documented..."